While pilotage services are not compulsory to enter Gasp harbour, they are usually available and used by foreign-going ships arriving and departing this port. Canadian coastal traders such as the JADE STAR rarely if ever take pilots to enter Gasp harbour, as their crews are well versed in the local knowledge necessary to execute these manoeuvres. It was the master's practice to maintain full speed if the conditions permitted because the ship's manoeuvrability was enhanced at higher speeds. No reduction in speed was planned for the entrance into Gasp harbour. At the moment the master countermanded the port helm order, he placed the engine control at half ahead. Approximately two and a half minutes later the vessel grounded. Given the momentum of the vessel, there would have been minimal reduction in the speed of the vessel during that period. Good seamanship dictates that speed be adjusted according to the prevailing conditions of light or darkness, sea room, traffic, weather conditions, available navigational aids and other restrictions. the narrows at the entrance to Gasp harbour are approximately 2.5 cables wide and a major change of course is necessary at this point; in winter months the two lighted buoys at the narrows are replaced by one unlit winter spar buoy; the RACON was not operational;[3] and certain key radar targets such as Sandy Beach Bar were not visible on radar; it is reasonable to conclude that a speed of 12 knots was excessive under these conditions. At a speed of approach of 12 knots, the bridge team had two and a half minutes to resolve an ambiguous situation before the grounding. At 6 knots, the team would have had five minutes to plot the vessel's position and take appropriate action. Both the OOW and the master reported that the range lights were very bright. Their night vision was further affected by the illumination of the deck lights some minutes before arrival in the narrows. To determine the alter-course position at the narrows, the OOW had set up an electronic bearing marker (EBM) for the next course to steer of 270 T, and a variable range marker at 0.7 nautical mile from the small point of land ahead. This allowed 650 feet advance for a 37-degree course alteration and was within the manoeuvring characteristics of the vessel. By remaining on the ranges until the alter-course distance was achieved, and having the EBM clear the port hand buoy HD-9 as confirmation, he was ready to execute the course alteration. This is consistent with good conning practice, but is not complete in itself. The last plotted position of the vessel was at 0440, 40 minutes before the grounding. Although most other aspects of the passage plan seem to have been well planned and executed, the fact that the vessel's progress was not adequately monitored (by positively fixing the position on the chart at more frequent intervals during the approach) increased the possibility of a grounding. At about 0437 the master had assumed de facto con of the vessel by countermanding the OOW's port helm order. He relied on the fact that Sandy Beach Bar was not showing up on the radar, indicating to him that the vessel must not have been as far advanced as the OOW thought. The fact that the X-band radar was not functional may have had an effect at this juncture. An X-band radar is generally better at picking up low-lying objects and it might have indicated Sandy Beach Bar, had it been operational. The master did not believe the radar echo to port was buoy HD-9. Additionally, he assumed the radar echo ahead (at about six cables) to be a band of ice and not the shore of Presqu'le de Penouille, believing that another point of land, approximately five cables north-west of the rear range light, was this feature. Once a hypothesis is formed, it is resistant to change. Having made certain assumptions, the master became susceptible to what is termed confirmation bias or hypothesis locking. He chose to interpret the information available to him in a manner that confirmed the assumptions made; the other, equally valid information available (the radar echo of buoy HD-9 and the GPS alarm) was not taken into account.[4] The effect of hypothesis locking is so great that it may take the intervention of another person with contradictory information to overcome it. In this instance, however, the OOW did not challenge the master's intervention and immediately relinquished the con of the vessel to the master. The passage plan, as indicated on the vessel's chart (number 4416), showed buoys HD-8 and HD-9 as being in position at the entrance to Gasp harbour. On 9 October 1998 the Canadian Coast Guard broadcast NOTSHIP L-2350 announced the lifting of summer buoys and the mooring of winter spar buoys in the Laurentian Region. Mariners were requested to contact the appropriate marine communications station for detailed information on the progress of the work. As of 7 December 1998 Coast Guard radio stations were in possession of a report indicating that buoy HD-8 had been lifted for the winter season and buoy HD-9 had been replaced by an unlit winter spar. This information was available to any mariner who requested it. If vessels' masters and navigating officers are to assume pilotage duties in non-compulsory pilotage areas, a proper and complete passage plan is necessary. The fact that no note had been made on the chart or elsewhere to indicate to the bridge team the special status of buoys HD-8 and HD-9 created ambiguity and confusion at a critical moment. Specifically, the OOW believed a winter spar to be present in place of buoy HD-9, whereas the master believed that both buoys had been removed for the winter. Although the GPS alarm sounded, announcing the vessel's arrival at the alter-course position to steer 270 T, the alarm was silenced without realizing the importance of this signal, verifying its validity, or announcing this to the master, who now had the con. This indicates less-than-adequate bridge resource management (BRM). A characteristic of good BRM is a balance between the authority of the master (or pilot) and the assertiveness of the bridge team--and, in particular, of the OOW. In this instance the OOW was thrown into doubt the minute the master countermanded the port wheel order. It was later determined that the master had countermanded the order on the basis of incomplete information. Unable to confirm the vessel's position with the electronic aids at his disposal, the OOW tried to find, visually, winter spar buoy HD-9 with the aid of the ship's searchlight. His preoccupation with this task may have contributed to the lack of importance placed on the GPS alarm. This again indicates less-than-adequate BRM. Another element of good BRM is the judgment and decision-making ability of the master and bridge team. Among other things, the master must assess the quality of information being used by the rest of the bridge team. In this instance the master did not correctly assess the accuracy of the radar information being used by the OOW while the vessel was approaching the alter-course position.Analysis While pilotage services are not compulsory to enter Gasp harbour, they are usually available and used by foreign-going ships arriving and departing this port. Canadian coastal traders such as the JADE STAR rarely if ever take pilots to enter Gasp harbour, as their crews are well versed in the local knowledge necessary to execute these manoeuvres. It was the master's practice to maintain full speed if the conditions permitted because the ship's manoeuvrability was enhanced at higher speeds. No reduction in speed was planned for the entrance into Gasp harbour. At the moment the master countermanded the port helm order, he placed the engine control at half ahead. Approximately two and a half minutes later the vessel grounded. Given the momentum of the vessel, there would have been minimal reduction in the speed of the vessel during that period. Good seamanship dictates that speed be adjusted according to the prevailing conditions of light or darkness, sea room, traffic, weather conditions, available navigational aids and other restrictions. the narrows at the entrance to Gasp harbour are approximately 2.5 cables wide and a major change of course is necessary at this point; in winter months the two lighted buoys at the narrows are replaced by one unlit winter spar buoy; the RACON was not operational;[3] and certain key radar targets such as Sandy Beach Bar were not visible on radar; it is reasonable to conclude that a speed of 12 knots was excessive under these conditions. At a speed of approach of 12 knots, the bridge team had two and a half minutes to resolve an ambiguous situation before the grounding. At 6 knots, the team would have had five minutes to plot the vessel's position and take appropriate action. Both the OOW and the master reported that the range lights were very bright. Their night vision was further affected by the illumination of the deck lights some minutes before arrival in the narrows. To determine the alter-course position at the narrows, the OOW had set up an electronic bearing marker (EBM) for the next course to steer of 270 T, and a variable range marker at 0.7 nautical mile from the small point of land ahead. This allowed 650 feet advance for a 37-degree course alteration and was within the manoeuvring characteristics of the vessel. By remaining on the ranges until the alter-course distance was achieved, and having the EBM clear the port hand buoy HD-9 as confirmation, he was ready to execute the course alteration. This is consistent with good conning practice, but is not complete in itself. The last plotted position of the vessel was at 0440, 40 minutes before the grounding. Although most other aspects of the passage plan seem to have been well planned and executed, the fact that the vessel's progress was not adequately monitored (by positively fixing the position on the chart at more frequent intervals during the approach) increased the possibility of a grounding. At about 0437 the master had assumed de facto con of the vessel by countermanding the OOW's port helm order. He relied on the fact that Sandy Beach Bar was not showing up on the radar, indicating to him that the vessel must not have been as far advanced as the OOW thought. The fact that the X-band radar was not functional may have had an effect at this juncture. An X-band radar is generally better at picking up low-lying objects and it might have indicated Sandy Beach Bar, had it been operational. The master did not believe the radar echo to port was buoy HD-9. Additionally, he assumed the radar echo ahead (at about six cables) to be a band of ice and not the shore of Presqu'le de Penouille, believing that another point of land, approximately five cables north-west of the rear range light, was this feature. Once a hypothesis is formed, it is resistant to change. Having made certain assumptions, the master became susceptible to what is termed confirmation bias or hypothesis locking. He chose to interpret the information available to him in a manner that confirmed the assumptions made; the other, equally valid information available (the radar echo of buoy HD-9 and the GPS alarm) was not taken into account.[4] The effect of hypothesis locking is so great that it may take the intervention of another person with contradictory information to overcome it. In this instance, however, the OOW did not challenge the master's intervention and immediately relinquished the con of the vessel to the master. The passage plan, as indicated on the vessel's chart (number 4416), showed buoys HD-8 and HD-9 as being in position at the entrance to Gasp harbour. On 9 October 1998 the Canadian Coast Guard broadcast NOTSHIP L-2350 announced the lifting of summer buoys and the mooring of winter spar buoys in the Laurentian Region. Mariners were requested to contact the appropriate marine communications station for detailed information on the progress of the work. As of 7 December 1998 Coast Guard radio stations were in possession of a report indicating that buoy HD-8 had been lifted for the winter season and buoy HD-9 had been replaced by an unlit winter spar. This information was available to any mariner who requested it. If vessels' masters and navigating officers are to assume pilotage duties in non-compulsory pilotage areas, a proper and complete passage plan is necessary. The fact that no note had been made on the chart or elsewhere to indicate to the bridge team the special status of buoys HD-8 and HD-9 created ambiguity and confusion at a critical moment. Specifically, the OOW believed a winter spar to be present in place of buoy HD-9, whereas the master believed that both buoys had been removed for the winter. Although the GPS alarm sounded, announcing the vessel's arrival at the alter-course position to steer 270 T, the alarm was silenced without realizing the importance of this signal, verifying its validity, or announcing this to the master, who now had the con. This indicates less-than-adequate bridge resource management (BRM). A characteristic of good BRM is a balance between the authority of the master (or pilot) and the assertiveness of the bridge team--and, in particular, of the OOW. In this instance the OOW was thrown into doubt the minute the master countermanded the port wheel order. It was later determined that the master had countermanded the order on the basis of incomplete information. Unable to confirm the vessel's position with the electronic aids at his disposal, the OOW tried to find, visually, winter spar buoy HD-9 with the aid of the ship's searchlight. His preoccupation with this task may have contributed to the lack of importance placed on the GPS alarm. This again indicates less-than-adequate BRM. Another element of good BRM is the judgment and decision-making ability of the master and bridge team. Among other things, the master must assess the quality of information being used by the rest of the bridge team. In this instance the master did not correctly assess the accuracy of the radar information being used by the OOW while the vessel was approaching the alter-course position. Shortly after the JADE STAR departed from the port of Qubec for Gasp, the X-band radar failed and was inter-switched to the S-band receiver/transmitter for the rest of the voyage. During the approach to Gasp harbour, some key navigational aids at the entrance to the harbour had been replaced for the winter season or were inoperative; buoy HD-9 had been replaced by a winter spar, buoy HD-8 had been removed for the winter, and the RACON placed on the rear range light of Presqu'le de Penouille was not operational. No note was made on the chart to indicate these changes to the charted information, nor were these changes brought to the attention of the master. The night vision of the bridge team was adversely affected by the brightness of the range lights on Presqu'le de Penouille, which were close together, and by the ship's deck lights. The JADE STAR entered the narrows at the entrance to Gasp harbour in darkness, at full speed and under the con of the OOW. During the approach, the vessel's progress along her intended route was not monitored by regularly plotting positions on the chart at appropriate intervals. The master did not correctly assess the accuracy of the radar information being used by the OOW as the vessel was approaching the alter-course position. On the basis of his differing interpretation of the radar information being used by the OOW, the master countermanded a helm order given by the OOW, and also reduced speed. When the master countermanded the OOW's helm order, the OOW immediately relinquished control of the vessel to the master. The GPS alarm, which had been set to sound when the vessel arrived at the alter-course position chosen for the original passage plan, sounded shortly after the master took the con of the vessel. The alarm was silenced without the members of the bridge team discussing it. After relinquishing the con, the OOW did not challenge the master's actions but engaged in an action of secondary importance, an attempt to find the spar buoy visually with the aid of the ship's searchlight. As there was no BRM regime in place, the OOW was not comfortable challenging the master's actions, and he did not do so.Findings Shortly after the JADE STAR departed from the port of Qubec for Gasp, the X-band radar failed and was inter-switched to the S-band receiver/transmitter for the rest of the voyage. During the approach to Gasp harbour, some key navigational aids at the entrance to the harbour had been replaced for the winter season or were inoperative; buoy HD-9 had been replaced by a winter spar, buoy HD-8 had been removed for the winter, and the RACON placed on the rear range light of Presqu'le de Penouille was not operational. No note was made on the chart to indicate these changes to the charted information, nor were these changes brought to the attention of the master. The night vision of the bridge team was adversely affected by the brightness of the range lights on Presqu'le de Penouille, which were close together, and by the ship's deck lights. The JADE STAR entered the narrows at the entrance to Gasp harbour in darkness, at full speed and under the con of the OOW. During the approach, the vessel's progress along her intended route was not monitored by regularly plotting positions on the chart at appropriate intervals. The master did not correctly assess the accuracy of the radar information being used by the OOW as the vessel was approaching the alter-course position. On the basis of his differing interpretation of the radar information being used by the OOW, the master countermanded a helm order given by the OOW, and also reduced speed. When the master countermanded the OOW's helm order, the OOW immediately relinquished control of the vessel to the master. The GPS alarm, which had been set to sound when the vessel arrived at the alter-course position chosen for the original passage plan, sounded shortly after the master took the con of the vessel. The alarm was silenced without the members of the bridge team discussing it. After relinquishing the con, the OOW did not challenge the master's actions but engaged in an action of secondary importance, an attempt to find the spar buoy visually with the aid of the ship's searchlight. As there was no BRM regime in place, the OOW was not comfortable challenging the master's actions, and he did not do so. The JADE STAR ran aground when, on scanty and erroneous information, a critical course alteration was delayed. Contributing factors were the speed of the vessel under the prevailing circumstances and the lack of a recent fix to positively determine both the vessel's position and her progress along the intended track. The absence both of a BRM environment (such that the OOW would have been comfortable challenging the master's actions) and of a complete, pre-determined passage plan also contributed to the grounding. Other contributing factors were: during a critical manoeuvre the superior performance of the X-band radar was unavailable; the bridge team's night vision was less than optimal; and certain navigational aids (the fixed RACON and buoy HD-8) were not available to the bridge team.Causes and Contributing Factors The JADE STAR ran aground when, on scanty and erroneous information, a critical course alteration was delayed. Contributing factors were the speed of the vessel under the prevailing circumstances and the lack of a recent fix to positively determine both the vessel's position and her progress along the intended track. The absence both of a BRM environment (such that the OOW would have been comfortable challenging the master's actions) and of a complete, pre-determined passage plan also contributed to the grounding. Other contributing factors were: during a critical manoeuvre the superior performance of the X-band radar was unavailable; the bridge team's night vision was less than optimal; and certain navigational aids (the fixed RACON and buoy HD-8) were not available to the bridge team. The owners of the JADE STAR are reviewing the need for formal BRM training for their deck officers and masters. Additionally, the owners have revised the company's bridge standing orders, and company circular G-93-04, emphasizing the need to obtain position fixes (to monitor accurately a ship's progress) and requiring that a safe vessel speed be determined taking into account the following factors: restricted waters, darkness, and the adequacy of the navigational aids available. As a result of this grounding, the Canadian Coast Guard will re-examine the level of service for Gasp harbour with respect to fixed and floating aids to navigation.Safety Action The owners of the JADE STAR are reviewing the need for formal BRM training for their deck officers and masters. Additionally, the owners have revised the company's bridge standing orders, and company circular G-93-04, emphasizing the need to obtain position fixes (to monitor accurately a ship's progress) and requiring that a safe vessel speed be determined taking into account the following factors: restricted waters, darkness, and the adequacy of the navigational aids available. As a result of this grounding, the Canadian Coast Guard will re-examine the level of service for Gasp harbour with respect to fixed and floating aids to navigation.